Provider Demographics
NPI:1023116852
Name:OTERO, MISAEL JOSUE (DDS)
Entity type:Individual
Prefix:DR
First Name:MISAEL
Middle Name:JOSUE
Last Name:OTERO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 CAROLINA BEACH AVE N APT 2B
Mailing Address - Street 2:
Mailing Address - City:CAROLINA BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28428-6096
Mailing Address - Country:US
Mailing Address - Phone:910-458-4559
Mailing Address - Fax:
Practice Address - Street 1:509 OLDE WATERFORD WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4125
Practice Address - Country:US
Practice Address - Phone:910-383-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC80191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901132Medicaid